Evaluating implementation strategies to support documentation of veterans' care preferences

Objective: To evaluate the effectiveness of feedback reports and feedback reports + external facilitation on completion of life-sustaining treatment (LST) note the template and durable medical orders. This quality improvement program supported the national roll-out of the Veterans Health Administration (VA) LST Decisions Initiative (LSTDI), which aims to ensure that seriously-ill veterans have care goals and LST decisions elicited and documented. Data Sources: Primary data from national databases for VA nursing homes (called Community Living Centers [CLCs]) from 2018 to 2020. Study Design: In one project, we distributed monthly feedback reports summarizing LST template completion rates to 12 sites as the sole implementation strategy. In the second involving five sites, we distributed similar feedback reports and provided robust external facilitation, which included coaching, education, and learning collaboratives. For each project, principal component analyses matched intervention to comparison sites, and interrupted time series/segmented regression analyses evaluated the differences in LSTDI template completion rates between intervention and comparison sites. Data Collection Methods: Data were extracted from national databases in addition to interviews and surveys in a mixed-methods process evaluation. Principal Findings: LSTDI template completion rose from 0% to about 80% throughout the study period in both projects' intervention and comparison CLCs. There were small but statistically significant differences for feedback reports alone (comparison sites performed better, coefficient estimate 3.48, standard error 0.99 for the difference between groups in change in trend) and feedback reports + external facilitation (intervention sites performed better, coefficient estimate -2.38, standard error 0.72). Conclusions: Feedback reports + external facilitation was associated with a small but statistically significant improvement in outcomes compared with comparison sites. (14) Brown University School of Public Health, Warwick, Rhode Island, USA (15) Stanford University School of Medicine, Stanford, California, USA (16) Sinclair School of Nursing, University of Missouri, Columbia, Missouri, USA (17) Leonard Davis Institute, Philadelphia, Pennsylvania, USA Correspondence Joan G. Carpenter, Organizational Systems and Adult Health, University of Maryland School of Nursing, Baltimore, MD, USA; Corporal Michael J. Crescenz VAMC, Philadelphia, PA, USA; Department of Biobehavioral Health Sciences, University of Pennsylvania School of Nursing, Philadelphia, PA, USA. Email: joan.carpenter@umaryland.edu Funding Information Quality Enhancement Research Initiative, Grant/Award Number: QUE 15-288 The large increases in completion rates are likely due to the well-planned national roll-out of the LSTDI. This finding suggests that when dissemination and support for widespread implementation are present and system-mandated, significant enhancements in the adoption of evidence-based practices may require more intensive support. KEYWORDS advance care planning, implementation science, interrupted time series analysis, nursing homes, United States Department of Veterans Affairs, Veteran What is known on this topic * Audit with feedback involves the collection and summary of clinical performance data over a specified period to monitor, evaluate, and modify clinician behavior. * Without cointerventions such as facilitation, feedback interventions have been shown to have only a modest positive impact on behavior change needed to implement evidence-based practices. * Facilitation strategies may incorporate supporting clinical champions, learning collaboratives, and coaching that allow for tailored approaches to implementation. What this study adds * The feedback intervention we deployed that included feedback and robust facilitation showed a statistically significant positive impact between intervention and comparison sites than a similar project that included feedback only. * Our findings suggest that it is important to couple feedback with facilitation strategies to achieve impact. * In-depth assessment of implementation interventions, especially feedback reports, is important to better understand their perceived usefulness to the end user.
1 | INTRODUCTION People receiving care in nursing homes are often seriously ill and frail and frequently face critical decisions about care. (1-3) Therefore, determining care preferences, particularly about life-sustaining [...]